Five states have the most balanced pain
policies in the country, according to a
report card released last year. They are
Kansas, Michigan, Virginia, Wisconsin and
Oregon. All received a grade of A in
“Achieving Balance in State Pain Policy: A
Progress Report Card,” the July 2008 report
found.

“States that have an ‘A’ have been able
to adopt a number of state laws,
regulations, guidelines and policies that
promote the safe and effective use of opioid
medications without establishing barriers to
their use,” said Aaron M. Gilson, director
of the U.S. Program at the University of
Wisconsin Pain & Policy Studies Group
(PPSG).

The study, which was published by PPSG,
evaluated states based on their ability to
support public health with proper pain
management protocols and, at the same time,
protect public safety with legislation to
protect against drug abuses. The report
termed this dual function the Central
Principle of Balance.

“Balanced policies have the potential to
enhance pain management while avoiding the
potential to interfere with such treatment,”
according to the report.
Still, many states have policies that impede
medical practitioners’ medical use of pain
medications. Also, certain state drug abuse
laws interfere with the legitimate use of
pain medications.

“Many states have policies that create
barriers to patients getting their pain
treated adequately, or are silent about
recognizing pain relief as part of quality
healthcare practice; it is these types of
policies we are trying to improve,”
background information on the report said.

Criteria for determining grades
To judge state policies, the PPSG developed
16 criteria based on the Central Principle
of Balance. Essentially, it analyzed states’
policy language to determine whether it
promoted pain management or hurt pain
management.
The PPSG considered positive those
provisions that encouraged pain management
and recognized it as a part of general
practice. Also recognized as good pain
policies were those that treated the medical
use of opioids as legitimate professional
practice and did not confuse physical
dependence or analgesic tolerance with
“addiction.”

By contrast, it considered negative those
provisions that included language that
stigmatized pain management. It also
disapproved of those provisions that
considered opioids a treatment of last
resort, those that implied the medical use
of opioids to be outside legitimate
professional practice, and provisions that
confused physical dependence or analgesic
tolerance with “addiction.”

The punitive nature of many pain policies
hinders many practitioners from using
medications to alleviate pain, according to
the report. Health professionals may be
reluctant to prescribe such medications
because of the risk of violating laws that
aim to prevent trafficking and abuse of
controlled substances. Such regulations not
only restrict healthcare decision making,
but they also communicate negative messages
about pain management and using pain
medications, according to the report.

Progress over the years
Over the last eight years, state pain
policies have become more balanced, the
report found. Seven states showed positive
grade changes since 2007. No states received
a D, D+ or F, and no state’s grade decreased
since last year or since 2000. Also, in
2008, for the first time in recent years, no
state added restrictive or ambiguous policy
language.

“The momentum of positive policy change,
first reported in 2003, seems to be
thriving,” the report noted.

Based on findings from five separate PPSG
evaluations of state pain policies, each
state was assigned a grade for 2000, 2003,
2006, 2007 and 2008. Most states lie
somewhere in the middle of the grade scale
last year, according to the report.
While five states received the highest
grade, a total of 11 states, including
Alabama, Massachusetts, Rhode Island and
Utah, received a B+. The largest number of
states—17—received a B. These states ranged
from Arkansas to Florida, to Hawaii to South
Dakota. Meanwhile, 12 states received a C+
and six states received a C. (The District
of Columbia, considered a state for the
report, received a C+.)

Overall, states are becoming more
progressive in terms of their pain policies,
the report suggested. The difference between
achieving a low grade and a high grade often
was simply a matter of adopting new
statutory language and discarding outdated
provisions. Georgia, as an example, rose
from a D+ to a B from 2007 to 2008 with its
adoption of a provision recognizing the
medical use of opioids as a part of
legitimate professional practice. It also
replaced a restrictive medical board
guideline adopted in 1991 with a policy
based on the Federation of State Medical
Board’s “Model Policy for the Use of
Controlled Substances for the Treatment of
Pain.” This state showed the biggest
improvement in its pain policies from 2007
to 2008.

Still other states also took positive
steps to recognize the importance of pain
medications. Oregon jumped to an A in 2008
from a B+ in 2007 by repealing the term
“intractable pain” from statute. Maine,
meanwhile, moved from a B to a B+ over those
same two years by adopting a provision
recognizing that the use medical use of
opioids is part of legitimate professional
practice.

Room for improvement
Unfortunately, too many onerous policies
still exist throughout the country,
according to the report. Drug-abuse laws
that interfere with legitimate medical
practice and patient care pose a problem.

“Many states now face the challenge not
only of adopting positive policies, but of
removing restrictive language from
legislation or regulations,” according to
the report. “Even for states that have
achieved an A, there remains the potential
for additional policy activity (however
well-intentioned) that might introduce
potentially restrictive requirements or
limitations.”

Gilson feels dismayed about the extent to
which archaic definitions of addiction in
state laws have largely remained unchanged
in the last eight years. Many of those
definitions are based on a definition from
federal law from the 1970s, he noted.
“One thing that hasn’t been addressed is
definitions for patients who are taking
opioids but have developed dependence,” he
said. “They could be classified as an addict
in 16 states.”

Some states face the challenge of getting
rid of negative statutory language. While
New York and Texas have repealed restrictive
legislative or regulatory language, they
still have a large number of negative
provisions, the report said.
“There’s been a lot of effort to remove
legal barriers that have persisted for many
years, if not decades,” Gilson said. “But
more still needs to be done.”

Encourage states to change
To improve their attitudes toward pain
management, many states have developed task
forces, commissions, advisory councils, and
convened summit meetings. Such bodies should
work to evaluate a state’s pain policies.
Membership should include governmental and
non-governmental stakeholders, and dedicated
staffing should be available, the report
recommends.

As states continue to adopt balanced
policies toward pain management, they need
to communicate that to professional
caregivers, according to John R. Seffrin,
CEO of the American Cancer Society.

“States must effectively inform the
medical community about improved pain
policies so people with pain can benefit
from them,” he said in a public statement.
“Patients, health organizations, health care
professionals, regulatory officials,
licensing boards, and policymakers all have
a role to play to promote a balanced
approach to pain control policy and
practice.”

PPSG expects to release another report
about pain as it relates to nursing practice
policy in 2011.
To learn about states’ individual pain
initiatives and to find state contacts,
visit the American State Pain Initiative’s
Web site at www.aspi.wisc.edu. Click on
“State Pain Initiatives” on the left
navigation column.
Also, for more information about pain for
patients, caregivers and healthcare
professionals, go to the American Pain
Foundation’s Web site at
www.painfoundation.org.